http://dx.doi.org/10.1590/S0080-62342012000400019

IRN.
Public Health Specialist. Master in Nursing. Professor at Universidade Comunitária
da Região de Chapecó. Member of the Center for Research and Studies
on Nursing, Quotidian, Imaginary and Health in Santa Catarina and the Fogueira
Group for Studies and Research on Gender. Chapecó, SC, Brazil. carmenlhm@brturbo.
com.brIIPh.D. in Nursing. Adjunct Professor of the Nursing Department,
Federal University of Santa Catarina. Head of the Center for Research and Studies
on Nursing, Quotidian, Imaginary and Health in Santa Catarina. Florianópolis,
SC, Brazil. jussarague@gmail.comIIIPh.D. in Human Sciences. Professor at da Universidade Comunitária
da Região de Chapecó. Coordintor of the Masters Program in Social
Policies and Regional Dynamics. Head of the Group for Studies and Research on
Gender. Chapecó, SC, Brazil. aldana@unochapeco.edu.br

Abortion, a current
reality in our society, is a complex challenge for healthcare professionals.
The objective of this article is to report the representations that Primary
Healthcare nurses from the city of Chapecó (SC) have regarding the care
of women experiencing abortion/unsafe abortion. This is a qualitative, exploratory-descriptive
study. Data were collected by means of focal groups comprised of eight nurses,
and then analyzed using the method of Collective Subject Discourse Analysis.
The discourses indicate that the care provided is permeated with conflicts between
assuming an attitude against abortion, supporting the women or remaining impartial.
The representation of the preservation of life, a principle taught by professional
training and Christian tradition, triggers attempts to convince the women to
avoid the abortion. When nurses are not successful in trying to help women find
a safe alternative, they advise them to go home and think about the situation,
making it clear to the women that she is not the professional who performs the
abortion and abandoning the women...

Abortion is a reality
in our society. It is also a taboo subject, a complex challenge for health professionals,
and an extreme situation that involves matters of life or death:

Biological life
or death of a future human being; existential life and death of dreams, projects
and aspirations; life and death in every way, of millions of women, as a result
of the sequelae caused by illegal abortion"(1).

This theme allows
for multiple interpretations and represents diverse interests of social institutions,
and there is no consensus on the issue. It is a forbidden subject whispered
about in corridors and almost never discussed in society, lying at the heart
of the family, school and among health professionals.

Globally, 25% of
pregnancies end in induced abortion, which corresponds to approximately 50 million
abortions annually. Of this total, 20 million are performed under unsafe conditions,
the underlying cause of approximately 13% of maternal mortality. Adolescents
and women under the age of 24 comprise 46% of this epidemiological scenario(2).
It should be pointed out that this unsafe practice happens mainly in countries
where abortion is restricted or illegal, where many women, as a result of unplanned
or unwanted pregnancies, resort to the practice of illegal abortion(3).

This reality shows
that, despite the criminalization of abortion in many countries, women who undergo
abortion feel trapped and distressed to the point of ignoring the legal consequences
of their actions and disregarding the risk to their own life in order to remedy
what seems to them an untenable situation. This is because the laws are doomed
to minimal success and the woman must solve what, to her, represents a significant,
life-altering problem(4).

In Brazil, where
abortion is a crime (except in cases of rape or life-threatening situations
to the health of women), the rates of maternal mortality due to abortion have
not decreased and persist with alarming incidence, a scenario worthy of a
more serious treatment than the one that has been so far given in our society(3).

Nationally, women's
movements in the first and second Conferences on Public Policies for Women have
demanded the decriminalization of abortion, supported by the platforms of action
signed by the Brazilian government in the UN-sponsored conferences in recent
decades(5).

The issues surrounding
abortion gain political relevance when they exceed the boundaries of the private
universe, of individual life, and become part of the agenda of the country's
political life, as well fodder for discussion forums on national and international
sexual and reproductive rights.

The issue is being
discussed in the current Brazilian health scenario, because, according to the
declaration of the Minister of Health during the first half of 2007, abortion
is a public health issue and needs to be faced by society and by the National
Congress(6). This leads the speech beyond morality and legality,
releasing the debate into the spectrum of health services, among managers and
professionals, not only within the hospital scope, but also within Primary Healthcare.

Based on this understanding,
on September 18, 2007, the Ministry of Health, aiming at expanding knowledge
on the subject of Women's Health on issues relating to teenage pregnancy and
abortion, released an announcement promoting research on these issues(7).

The current National
Plan for Women policies includes in women's healthcare the understanding
of biological, epidemiological, social, cultural, ethical and anthropological
articulated aspects in a context of performance within a multidisciplinary team(3).
It is the theme of discussions involving population groups which present morbimortality
indicators related to the major public health problems in the world and especially
in Brazil(3).

In the professional
approach, the issue of abortion raises moral, religious and ethical questions,
and assisting with abortions has been permeated with the concept of committing
a crime, without reference to the reproductive rights and issues of the underground
and social movement(1).

The relationship
between Primary Health Care and the abortion theme occurs because this is usually
the gateway for women within the Single Health System (SUS). Those women who,
for various reasons, are assisted in the promotion, prevention and/or recovery
of health significantly expand their social life in this service, generating
confidence and the freedom to express feelings and desires to the professionals
who assist them.

The professional
experience lived by the author of this study, in the course of working as a
welfare nurse and coordinator of a Polyclinic of the Municipal Health Department
of Chapecó (SC), led to the desire to investigate the theme related to
nursing care in Primary Health Care. During this professional period, during
the registration of a pregnant client in the Prenatal Program, the women expressed
a desire to have an abortion. Faced with this comment, it took me a few seconds
to think about what to say. The only thought that occurred to me at that time
was: - This is not up to me and not up to the health service. After a few days,
the client returned, reporting that she had used the drug misoprostol, but that
it was not having the desired effect (abortion). This situation allowed the
perception of trust by the client, because she could have omitted her desire
to abort.

The drug misoprostol,
used by women in the practice of abortion, is responsible for reducing the number
of hospitalizations due to the popularity of its use in the early 1990's, which
resulted in reduced complications from induced abortion, since women using such
a drug abort at home with no need to make use of health services, either those
of Primary Health Services or hospital services(8).

This fact prompted
some questions: how should the issue of abortion/induced abortion be dealt with
as a personal matter and as a professional caregiver? What professional training
does one have for referral of issues related to abortion/unsafe abortion?

In seeking answers
to these questions, it was determined that in 2005 the Ministry of Health developed
technical standards regarding the humanization of abortion, taking into account
the definition of sexual and reproductive rights defined in the International
Conference on Population and Development (CIPD) held in Cairo in 1994 and in
the 4th World Conference on Woman, held in Beijing in 1995(9). These
conferences confirmed that sexual and reproductive rights must be envisaged
in human rights, and they recommended quality attention to all people, so that
they could exercise such rights(10).

The technical standard
Humanized Attention to Abortion, created with the objective of ensuring
women's human rights (included in these the sexual and reproductive rights),
provides guidance to support practitioners and health services, introducing
new approaches to care and attention to women in matters relating specifically
to abortion. The standard proposes to shelter and provide humanized assistance
to women seeking to establish trust, setting aside judgment, discrimination,
religious and moral precepts, respecting ethics, autonomy and decision-making
capacity(9).

When examining
issues relating to abortion discussed in the literature, there arises concerns
and anxieties related to personal and ethical dimensions in relation to this
practice, especially since, according to the Brazilian Penal Code, this is a
crime. In the ethical dimension, several questions come up: Is a complaint to
a Court of Law or another institution worth it since it is a crime? What are
the limits of ethics when the woman's life is at stake, as well as a potential
life? What ethical criteria and human rights apply in abortion care? What can
we offer as a health service? When obtaining a diagnosis of pregnancy, should
we question the woman if the pregnancy was a result of rape or not? If the answer
is yes, should we tell her legal rights? Regarding access to services in legal
cases - voluntary interruption of the pregnancy in cases of pregnancy resulting
from rape or involving risk to the mother's life - should we tell the mother
where they are performed?

Criminalizing induced
abortion would not be the most appropriate way to overcome the problems described
previously. Central issues are still set aside, such as the moral precepts,
religious values and beliefs in judging and discriminating against these women.
How do we deal with the meanings that are mobilized and reassessed at heart?

Seeking other literature
on the topic, articles were found in the databases that cover many of these
issues, including systematic reviews on abortion, issues related to epidemiology,
treatment and the points of view of women in relation to assistance provided
by professionals in situations of abortion within the hospital scope, enabling
elements for the study object context. In this process, it was important to
find the study entitled "Profissionais de saúde frente ao aborto legal
no Brasil: desafios, conflitos e significados"(11) (Health professionals
before legal abortion in Brazil: challenges, conflicts, and meanings), published
in 2003 in the Cadernos de Saúde Pública, which addresses the
issue from the perspective of the challenges, conflicts, and meanings for professionals
who provide assistance to women in cases of legal abortion.

This study aimed
at seeking the representations of the different professional categories of services
that have implemented assistance programs for women victims of sexual violence
in Paraíba and the Federal District. The results ranged from the concept
of pregnancy interruption as a right to addressing religious values, with abortion
seen as a sin(11).

With respect to
religious restrictions, the professionals were unanimous in stating that they
must maintain a neutral and impartial stance regarding the women's decision
and should not judge them by the practice of abortion. "The professional
should not persuade anyone to have or not to have an abortion" (physician).
Paradoxically, one professional said, "I decided to stay in the program to
help women not to interrupt the pregnancy" (physician)(11).

There is, on the
part of some professionals, the concern of being judged by society, being labeled
as "abortionists" and legally prosecuted for participating in the interruption
of pregnancy(11).

It is emphasized
that the main difference of the study mentioned refers to the representations
of professionals in cases of legal abortion, while this research focuses on
the problem of unsafe abortion, according to the following objective.

OBJECTIVE

Identify Primary
Healthcare nurses' representations regarding the practice of care provided to
women undergoing abortion/unsafe abortion in the city of Chapeco (SC).

METHOD

This is a qualitative
research, of the descriptive exploratory type, based on the Theory of Social
Representations(12).

This type of research
aims at assisting future studies, overcoming the empirical approaches of
social issues, exploring and describing a problem or situation that is insufficiently
known, showing a lack of organized knowledge regarding the existing problem
for individuals, for relations and for services(13-14).

In the delimitation
of the participants in the study, we observed the following criteria: being
a nurse (called female nurse (s) because most nursing professionals are
women); working in Primary Healthcare; having experienced in their working practice
situations related to abortion/unsafe abortion, and having agreed to take part
in the study as a free and informed subject.

Data were collected
using the Focal Group technique, which constitutes a specifically qualitative
approach to obtain information about the object of study, by means of (...)
conversation in small and homogeneous groups (...) coordinated by a moderator
capable of gaining the participation and the perspective of each and every one(15).

The Focal Group
was composed of eight nurses, and the meetings for the collection and validation
of data occurred in three stages, from July to September 2009. In the first
and second meetings, data were collected and in the third meeting, the participants
validated the data presented. The meetings were videotaped and the lines were
recorded.

The data were discussed
and analyzed in accordance with the methodological strategy of the Collective
Subject Discourse Analysis (CSD), because the speech brings more clarity to
social representations of the studied object while the set of representations
that conforms to an imaginary datum are collected.(16). It is
the rebuilt representation,

(...) with pieces
of individual speech, as in a puzzle, many synthetic discourses as deemed necessary
to express a given figure, i.e. a given thought or social representation
of a phenomenon.

The set of verbal
discourses issued by members of a group or a population, when asked questions
of a qualitative nature, corresponds to a triggered and manifested discursive
thought by means of thoughts of the group or the population people asked about
the theme. Therefore, it is through collective discourse that a population seeks
to express, as faithfully as possible, their thoughts on the theme(16).

Following the theoretical,
philosophical and methodological precepts of the qualitative research approach,
data analysis began simultaneously with the first meeting of the Focal Group
and concluded at the end of data collection. The analysis was performed according
to the four tools proposed in the strategy of the Collective Subject Discourse
Analysis: analysis, selection and grouping of key expressions (ECH); analysis
and grouping of central ideas (CI)/categories; analysis of the anchorage present
in key expressions; and construction of the Collective Subject Discourse Analysis
- CSD(16).

During data analysis,
we observed that presenting the position of the investigator in relation to
the issue is essential, considering that it is in the relationship between the
investigator and his object of study that one builds the interpretation and
analysis of empirical material and all methodological process. The moment the
investigator identifies his/her personal position, he/she is able to respect
and understand the different and complex attitudes that permeate the studied
problem. Speaking, therefore, about the personal position of the author of this
study, it takes into account the voluntary interruption of pregnancy as an act
relative to the empowerment of women, who can make ethical and responsible decisions
and responsibility for their own reproductive lives. In short, the investigator
stands in favor of freedom of decision for women facing an unwanted pregnancy.

The ethical aspects
of the research were observed throughout the development of the study: approval
of the research project by the Ethics in Human Research Committee with Human
Beings (CEPSH) of the Federal University of Santa Catarina (Certificate No.
159, Case 163/09, FR 261 928); and agreement to participate and maintain the
anonymity of the subjects involved according to the Terms of Consent.

RESULTS

The representations
of nurses working in Primary Healthcare in the city of Chapecó (SC) regarding
the care provided to women experiencing a situation of abortion/unsafe abortion
are presented below in the form of Collective Subject Discourse Analysis, constituted
by categories and subcategories of representations.

The category Concerns
and feelings triggered in the practice of this service' is represented by
the following speech:

It is a very
difficult situation. It stirs our feelings: it concerns the psychological
side of the woman and the fact that the child is not alive; there is sadness
and trauma for not having contributed to a safe abortion in cases of maternal
death or not having persuaded the woman not to abort; outrage, anger, prejudice
and criticism because she had unprotected sex, with so much information and
contraceptive methods available at the health unit; unrest, despair, anxiety
and impotence when there is willingness to help.

Permeated by this
category 'Concerns and feelings triggered in the practice of this service' and
by other categories and subcategories of representations, the development of
the service practice can be represented by the following diagram:

The conceptions
rooted in religious, cultural, family and vocational training often view abortion
as a crime, realizing that this practice of care should strive for maintenance
of life

personal, cultural
and, especially, religious values tell us: Let us populate the world! There
is always room for one more! There is a life and abortion is a crime.

Professional
training prepared us for the ethics and legality in the maintenance and preservation
of life, a principle to be pursued in professional practice.

These concepts
are shaken by conflicts between positioning against abortion, supporting women
in their decision or remaining impartial in the situation.

In general, there
are attempts to provide care maintaining impartiality.

The aim is being
impartial in care, but being impartial is difficult. Our values, culture,
religion and the principle of the profession ultimately reflect in our speech
in an attempt to prevent what we see as a crime.

In this sense,
we may subtly, by verbal and/or nonverbal expressions, attempt to reverse a
decision made regarding an abortion

One cannot be
impartial. We try to convince the woman not to abort, expressing the positive
side of having the child: it was God who sent it to you! He will take care
of you in the future.

I requested that
the health worker drop the little box in the mail box at the pregnant women's
home (folders about breastfeeding) I knew she was going to open it. After
two weeks, she came in bringing the package with her, saying she had talked
with her father about the pregnancy and that everything would be okay and
that she no longer wanted to abort.

Unlike this practice
of care, based on the concept of the human right to a decent life, there is
an impartial positioning and referral based on the concern for the future of
the child that is not aborted and the woman who, from her life experience, recognizes
that she will have no way to provide a decent life for this child.

Telling the woman
not to have an abortion because there is a life is useless. We do not know
how this child was conceived, whether it will have a decent life or not. We
do not know the economic and social resources of the woman who, if she does
not have the abortion, might let the child die afterwards, or the child may
suffer throughout its life: an abortion that was not abortion, it simply did
not have the mechanism.

The woman who,
from her experience, knows she will not cope with another child and thinks
of the child's future suffering in a situation of extreme misery, knows what
she's doing and should not be treated as a criminal.

Thinking about
having a child entails also thinking of the existence of a favorable structure
for one's life. In order for a human being to have a life, it does not mean
only to be in a corporeal body, breathing; it means also having access to
human rights.

Based on concern
for the future of the child that was not aborted, there is a category called
Social Abortion in this study: death can be in life, abortion in life:

Abortion involves
a whole social question, and this matter weighs heavily.

For this child
who was not aborted, there may be a lack of everything: family, food, warmth,
tenderness and lap. This is life.

Sometimes not
having an abortion is letting the child die later, because death can be in
life.

In this category,
there is the following subcategory: When we stand against abortion, social responsibility
in regards to the child is also ours.

Our position
opposed to abortion generates responsibility for the social situation experienced
by the child. What will become of the child tomorrow whom we have positioned
ourselves against aborting today? Today this child suffers sequelae and tomorrow
this child will be a drug addict, and will steal to support its needs.

This subcategory
is founded on the understanding that we all share and are actors in our society
- the events and facts present in a society reflect the actions and referrals
given by the various actors that make up society.

For professionals,
beyond the conflicts discussed previously, there is the conflict generated by
the recognition of the desperate situation of women and the legal and professional
limits in the desired referral of the situation:

For the woman
it is a desperate situation. It is very easy for us to say to that person
who is desperate: you did it; now you will have to assume responsibility for
it; you did not take care of yourself.

Today the responsibility
falls on the women. Surely men get out of it too easily.

There is concern
regarding the psychological effects on the woman due to the trauma of having
an abortion.

Professionals perceive
in this situation the woman in her existential context

She does not
need criticism, but rather someone who backs her up. One has to pay attention
to the situation the person is going through. Being a professional means not
forgetting that there is human being with 'n' problems and 'n' experiences.

Anchored to the
criminalization of abortion practice, such as the position of the State, there
is, among the professionals, the category of interpretation regarding the notion
that the system does not take into account their responsibility in meeting the
demand generated by this positioning

While this
situation impacts on health, there is a void. The system is not prepared to
meet this demand because it is an illegal practice. For being willing
to refer the woman to a reflective support service, other professionals also
suffer the limits of the law - It is not just the nursing staff that has
no support from referrals; even if we refer the expectant mother to the doctor's,
he/she will not know what to do. Depending on the availability of time, he
will only talk to her.

They understand
that there should be an immediate avenue for psychological support for these
women without having to wait two weeks or a month.

Even so, if she
still decides to have an abortion, there is the sense of abandonment in the
assistance provided to women

We would really
like to refer this situation as well, but when the woman is determined to
have an abortion, she is forced to go home to think, making it clear that
it is not up to me. We abandon her and she goes underground. She will have
to work it out for herself. After the abortion, if she comes back with an
infection, a problem, we resume care to restore her health.

Regarding the ethics
of the profession, speeches bring the lack of a clear and unanimous understanding
regarding the issues, noting contradictions in speeches

I would not report
it to the Guardian Council because it is not my role, not least because the
Council fights for the rights of the child. I would trigger it, for example,
if the mother were 16 years old and were a crack user placing the infant at
risk. I would not betray the woman, regardless of the situation. If there
is no way to prove that the abortion was induced, it is no use reporting it.
I would report if the woman was being pressured to induce abortion, but I
do not know if I would report it to the Guardian Council.

DISCUSSION

Because this is
a study that aimed at identifying representations, it adopted as reference the
Theory of Social Representations (TSR) - La Psychanalyse, son image som public(12).

According to the
Social Sciences, the representations come from the real experiences of human
interaction. Under this perspective, in recent years the Theory of Social Representations
has been used extensively in qualitative research in nursing(12).

The current practice
of health care, inserted in Social Sciences, includes a new look at the health/disease
process, situating and contextualizing the individual in his entirety, belonging
to a social and cultural environment. Investigating the social representations
in health/disease provides creative scientific studies involving subject care
and caregivers, considering, respectively, the representations of the health/disease
process and the care process, such as the individual or group caregiver(12).

The speeches express
the triggering of various conflicts in the practice of care, based on different
representations of the subject.

Conflicts originate
primarily from distinct views that do not mesh. On the contrary, each concept
requires a differentiated position in the referral of professional care.

The concept of
the maintenance of life, grounded on Christian tradition, professional training,
and the concept of each individual's responsibility in assuming the consequences
of their acts persuade the practice of care directed towards the attempt to
discourage abortion. Since the intent is supporting the right to a worthy life,
human rights and social responsibility in terms of non- aborted children resulting
from professional interference originate care practices from the perspective
of impartiality, where professionals do not try to reverse a woman's desire
for the right to make her own decisions regarding reproductive choice.

These concepts
are responsible for all kinds of feelings and concerns with respect to the child
who may not exist, the risk to a woman undergoing an unsafe abortion and the
non-aborted child living in the condition of social abortion.

These feelings
and concerns are exacerbated mainly due to the professional ethics issue, seeking
to maintain life and the position of the State in regards to induced abortion,
because it is understood that two lives are at stake: the child's life and the
woman who wants to have the abortion. This results in a justification of the
subtle position of being between the cross and the sword; that is, between
positioning themselves against abortion or remaining impartial, ignoring all
risks relevant to women in the practice of unsafe abortion.

With regard to
the feelings triggered by the fact that women do not take due care to avoid
an unwanted pregnancy, we professionals must reflect on the effectiveness of
health education related to family planning. This does not have to do only with
access to contraceptive methods, but must also contemplate, as a process, the
context and perspectives of women's lives, and who will be most likely to practice
family planning based on their life experiences.

It is pertinent,
upon concluding this discussion, to resume the discourse here on the so-called
Social Abortion: death can be in life, abortion in life:

The State, by not
allowing the right of women's autonomy and decision-making on issues concerning
reproduction, despite their efforts towards providing assistance to children
and adolescents, does not accommodate delinquent children, caving the street,
the sidewalk and the shelter below the bridge their home.

CONCLUSION

The professionals
committed to healthcare seek to develop their role considering the various aspects
and nuances that permeate the health of the population here in relation to women's
health. However, the representations relating to induced abortion grounded on
religious principles and cultural traditions will always be present in the collective
imagination, even if subtly, because they are part of relationships and communication
between caregivers and those needing care.

Impartiality regarding
such care happens when there is, in particular, careful representation of the
so-called social abortion, realizing the concern that the unwanted child
is aborted in life, calling the street, the sidewalk its home...

This study allowed
the identification of the representations of nurses regarding the practice of
care provided to women undergoing or contemplating having an abortion/unsafe
abortion in Primary Healthcare, as well as the need for the State to ensure
women's sexual and reproductive rights, allowing women and men to decide freely
and consciously to have children or not. Such positioning on the part of
the State could interfere with the redefinition of views on abortion practice,
beyond the psychological contribution to women regarding decision making, safety
and health of women and reduction of social abortion experiences.

From the moment
the practice of care begins in observing the woman's right to have control and
decision-making ability on issues relating to her sexuality free of coercion
and discrimination, and legitimized by the State, the ethical and professional
criteria are overlapped by moral and religious positions, which, quite often,
prevent a less biased healthcare service.